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3-Part Video Series Trailer
https://www.youtube.com/watch?v=59mFhX02ffk&feature=youtu.
be
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Leveraging Technology to Improve
Prior Authorization
Session #156 - February 13, 2019
Heather McComas, PharmD, Director, Administrative Simplification Initiatives, American Medical Association
Tyler Scheid, J.D., Senior Policy Analyst, Administrative Simplification Initiatives, American Medical Association
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Heather McComas, PharmD Director, Administrative
Simplification Initiatives, American Medical Association
Tyler Scheid, J.D. Senior Policy Analyst, Administrative
Simplification Initiatives, American Medical Association
We have no real or apparent conflicts of interest to report.
Conflicts of Interest
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Setting the Stage
Prior authorization (PA) physician survey data
PA Reform Initiatives
Prior Authorization and Utilization Management Reform Principles
Consensus Statement on Improving the Prior Authorization Process
Utilizing Technology to Improve PA
Leveraging Social Media for PA Policy Reform
AMA grassroots efforts
Questions
Agenda
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1. Recognize how PA negatively impacts patients and health care
professionals using available survey findings
2. Analyze the current status of electronic prior authorization (ePA)
adoption for prescription medications, identify current
impediments to adoption, and propose solutions to overcome
these barriers
3. Describe the challenges that must be addressed to achieve
widespread adoption of standardized, automated PA for medical
services
4. Explore use of technology to facilitate PA policy reforms
5. Outline how effective utilization of social media and grassroots
web technologies can drive important PA policy changes that will
benefit health care professionals, patients, and payers
Learning Objectives
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Setting the Stage
PA physician survey data
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Utilization Management Programs: Cost-containment
protocols requiring physicians to receive advanced
approval before a health insurer will cover a particular
drug or medical procedure
PA
Step therapy
Concerns:
Delayed patient treatment
Questioning practitioner’s medical judgment
Manual, time-consuming process for both providers and payers that
requires resources that could otherwise be spent on clinical care
The Problem
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1000 practicing physician respondents
40% PCPs/60% specialists
Web-based survey
29 questions
Fielded in December 2018
2018 AMA PA Survey Overview
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Average PA Response Wait Time
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Question: In the last week, how long on average did you and
your staff need to wait for a PA decision from health plans?
Source: 2018 AMA Prior Authorization Physician Survey
7%
7%
19%
19%
20%
11%
12%
5%
0% 20% 40% 60% 80% 100%
Don't know
More than 5 business days
3-5 business days
2 business days
1 business day
More than a few hours but less than 1 business day
A few hours
Under 1 hour
65% report
waiting at least
one business
day
26% report
waiting at least
three business
days
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Care Delays Associated With PA
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1%
0%
7%
44%
36%
11%
0%
20%
40%
60%
80%
100%
Always
Often
Sometimes
Rarely
Never
Don't Know
91% report
care delays
Question: For those patients whose treatment requires PA,
how often does this process delay access to necessary care?
Source: 2018 AMA Prior Authorization Physician Survey
Total does not equal 100% due to rounding.
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Treatment Abandonment
Associated With PA
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Question: How often do issues related to the PA process lead to patients abandoning
their recommended course of treatment?
4%
1%
20%
53%
21%
2%
0%
20%
40%
60%
80%
100%
Always
Often
Sometimes
Rarely
Never
Don't know
75% report that
PA can lead to
treatment
abandonment
Source: 2018 AMA Prior Authorization Physician Survey
Total does not equal 100% due to rounding.
Subtotal sums to 75% due to rounding.
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Impact of PA on Clinical Outcomes
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Question: For those patients whose treatment requires PA, what is your
perception of the overall impact of this process on patient clinical outcomes?
Source: 2018 AMA Prior Authorization Physician Survey
91%
8%
2%
Significant or somewhat NEGATIVE impact
No impact
Somewhat or significant POSITIVE impact
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Physician Perspective on PA Burdens
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Question: How would you describe the burden associated
with PA in your practice?
Source: 2018 AMA Prior Authorization Physician Survey
86%
12%
3%
High or extremely high
Neither high nor low
Low or extremely low
Total does not equal 100% due to rounding.
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Change in PA Burden Over the Last 5 Years
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Question: How has the burden associated with PA changed over
the last five years in your practice?
2%
10%
38%
50%
0%
20%
40%
60%
80%
100%
Increased significantly
Increased somewhat
No change
Decreased somewhat
or significantly
88% report PA
burdens have
increased over the
last five years
Source: 2018 AMA Prior Authorization Physician Survey
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Volume
31 average total PAs per physician per week
Time
Average of 14.9 hours (approximately two business days) spent each
week by the physician/staff to complete this PA workload
Practice resources
36% of physicians have staff who work exclusively on PA
Additional PA Practice Burden Findings
Source: 2018 AMA Prior Authorization Physician Survey
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PA Reform Initiatives
Principles and Consensus Statement
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Released in January 2017 by coalition of AMA and 16 other
organizations
Underlying assumption: utilization management will continue to be
used for the foreseeable future
Sound, common-sense concepts
21 principles grouped in 5 broad categories:
Clinical validity
Continuity of care
Transparency and fairness
Timely access and administrative efficiency
Alternatives and exemptions
Link to Principles: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/principles-with-signatory-page-for-slsc.pdf
Prior Authorization and Utilization
Management Reform Principles
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American Medical Association
American Academy of Child and
Adolescent Psychiatry
American Academy of Dermatology
American Academy of Family
Physicians
American College of Cardiology
American College of Rheumatology
American Hospital Association
American Pharmacists Association
American Society of Clinical
Oncology
Arthritis Foundation
Colorado Medical Society
Medical Group Management
Association
Medical Society of the State of
New York
Minnesota Medical Association
North Carolina Medical Society
Ohio State Medical Association
Washington State Medical
Association
Over 100 additional organizations have signed on as supporters of the
Workgroup efforts following the January 2017 release of the Principles.
Prior Authorization Reform Workgroup
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Released in January 2018 by the AMA, American Hospital
Association, America’s Health Insurance Plans, American
Pharmacists Association, Blue Cross Blue Shield Association,
and Medical Group Management Association
Five “buckets” addressed:
Selective application of PA
PA program review and volume adjustment
Transparency and communication regarding PA
Continuity of patient care
Automation to improve transparency and efficiency
GOAL: Promote safe, timely, and affordable access to
evidence-based care for patients; enhance efficiency; and
reduce administrative burdens
Link to Consensus Statement: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf
Consensus Statement on Improving the
Prior Authorization Process
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Utilizing Technology to
Improve PA
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Areas where solutions developed or well underway:
Automation to improve transparency and efficiency
Transparency and communication regarding PA
Areas where less work has been done on solutions:
Selective application of PA
PA program review and volume adjustment
Continuity of patient care
Using Technology to Address Areas of
the Consensus Statement
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Consensus:
Encourage health care providers, health systems, health plans, and pharmacy
benefit managers to accelerate use of existing national standard
transactions for electronic prior authorization (i.e., National Council for
Prescription Drug Programs [NCPDP] ePA transactions and X12 278)
Advocate for adoption of national standards for the electronic exchange
of clinical documents (i.e., electronic attachment standards) to reduce
administrative burdens associated with prior authorization
Advocate that health care provider and health plan trading partners, such as
intermediaries, clearinghouses, and EHR and practice management system
vendors, develop and deploy software and processes that facilitate prior
authorization automation using standard electronic transactions
Encourage the communication of up-to-date prior authorization and step
therapy requirements, coverage criteria and restrictions, drug tiers,
relative costs, and covered alternatives (1) to EHR, pharmacy system, and
other vendors to promote the accessibility of this information to health care
providers at the point-of-care via integration into ordering and dispensing
technology interfaces; and (2) via websites easily accessible to contracted
health care providers
Automation to Improve Transparency
and Efficiency
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What it is:
Automated exchange of patient clinical data between a provider
and a payer to facilitate utilization management determination
Integrated within providers workflow in practice management
systems (PMS)/electronic health records (EHR) (vs. requiring use
of separate payer website portal)
Uniform process across all payers
Why it’s needed:
PA process today is manual (phone, fax) and time-consuming for
both providers and payers
Current process leads to treatment delays and abandonment
Automation saves all stakeholders time and resources, improves
communication, and most importantly, improves patient care
Standard Electronic Prior Authorization
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Improvement on manual processes, but NOT a universal solution
Limitations/issues:
Providers must exit usual EHR workflow to access portals
Providers responsible for managing multiple log ins and
passwords
Each portal is unique, and the lack of consistency burdens
providers
Must learn individual nuances and adapt to each one
Requires significant amount of data reentry from EHRs
Any PA technological solution must have universal applicability in
order to satisfy provider needs and improve efficiency
The Problem with Portals
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Solution to improve prescription PA process:
NCPDP ePA
Solution to improve medical PA process:
X12 278 for medical services PA
Electronic PA Standards
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Standard History:
ePA process involves four transactions established in the NCPDP SCRIPT
standard
First published in NCPDP SCRIPT standard V2013071 (2013)
Legislative Mandates:
H.R. 6 SUPPORT for Patients and Communities Act (Section 6062) -
10/24/18
Standard, secure ePA system to be established no later than
January 1, 2021
Facsimile, a proprietary payer portal that does not meet standards
specified by the Secretary, or an electronic form shall not be treated
as an electronic transmission
States (including Minnesota, Delaware, and Ohio among others) have
passed legislation that requires payers to accept ePA requests for
prescription drugs
Prescription PA Process - ePA
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Payers:
96% of payers are committed to an ePA solution*
Vendors:
79% of EHRs are committed to implementing ePA*
Physicians:
Provider adoption of technology is sluggish
Only 51% of surveyed physicians were aware of ePA
technology
#
Status of Pharmacy ePA Adoption
# Source: 2017 AMA Prior Authorization Physician Survey
* 2018 CoverMyMeds ePA Scorecard
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Vendors not offering no-cost ePA solutions
Lack of payer support of ePA technology
Low physician awareness of ePA technology
Data not being auto-extracted from EHRs
Confusion/detraction of proprietary portals
Lack of transparency of PA requirements in EHRs at point of
prescribing
Pharmacy ePA Adoption Challenges
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Urge vendors to build/offer ePA solutions at no cost to physicians
Encourage all payers to support ePA technology
Increase physician education
Maximize technology to pull data from EHRs (vs reentry of data in
question sets)
Improve accuracy of formulary data/improve real-time pharmacy
benefit transactions
Overcoming ePA Adoption Challenges
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Committed to educating providers about the advantages of ePA
3-part video series Electronic Prior Authorization: A Better Way
AMA ePA Education Efforts
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X12 278 Health Care Services Review - Request for Review and
Response is HIPAA-mandated transaction for electronic PA
CAQH CORE Phase IV Operating Rules address X12 278
connectivity issues (compliance is voluntary)
CAQH CORE is developing additional Phase V Operating
Rules for X12 278 data content and web portals
Medical Services Electronic PA
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X12 278 implementation status
X12 278 adoption reported at 12% (down from 18% in 2016
CAQH Index)*
Barriers to adoption
Lack of support across stakeholder groups
Lack of an attachment standard to support clinical
documentation submission
Investment in proprietary portals
Multiple iterations of X12 278 to deliver final decision not
supported
Medical Services PA: X12 278 Adoption
Status and Challenges
*Source: 2018 CAQH Index Report
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Significant industry attention focused on finding solutions
CAQH CORE Prior Authorization Subgroup/Rules Work Group
WEDI Prior Authorization Subworkgroup
Rule-making for electronic attachment standard
Compliance enforcement for X12 278
Supporting multiple iterations/conversational nature of PA
transactions
Overcoming X12 278 Adoption Challenges
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Consensus:
Improve communication channels between health plans, health
care providers, and patients
Encourage transparency and easy accessibility of prior
authorization requirements, criteria, rationale, and program changes
to contracted health care providers and patients/enrollees
Encourage improvement in communication channels to support
(1) timely submission by health care providers of the complete
information necessary to make a prior authorization determination
as early in the process as possible; and (2) timely notification of PA
determinations by health plans to impacted health care providers
(both ordering/rendering physician and dispensing pharmacists) and
patients/enrollees
Transparency and Communication
Regarding PA
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Updated at predetermined times with data sets that are the same
for large groups of plan members
Example: NCPDP batch Formulary & Benefit files
Irregular/inconsistent updates result in outdated and inaccurate
information being presented to the prescriber
Only 43% of surveyed physicians indicated that information
about PA requirements in their EHRs is often or always
accurate*
In informal study using convenience sample of EHR
formulary data for 100,000 patients, only 33% of formularies
contained a least one drug with a PA flag (would expect
close to 100%)
#
Inaccurate EHR formulary data can lead to prescription
abandonment and medication adherence issues
EHR Coverage Information: Static Data
*Source: 2017 AMA Prior Authorization Physician Survey
# Data on file, AMA
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Dependent on details such as patient utilization that do not apply
equally to a large group of plan members
Examples:
Real-Time Prescription Benefit (RTPB)
HL7 Da Vinci Project
Newer technologies relay patient-specific, real-time coverage
information at the point of care
EHR Coverage Information:
Transactional Data
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What is RTPB?
System that delivers patient-specific drug benefit and cost
information within the e-prescribing workflow
Provides wide range of cost information including:
Out-of-pocket costs, co-pays, and financial assistance
programs, among others
Utilization management requirements (PA, step therapy)
Preferred pharmacy information
Provides visibility into patient-specific benefits at point of
prescribing
Supports provider-patient conversations about drug selection
during office visits, thereby increasing chances of medication
adherence
Real-Time Prescription Benefit
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RTPB Pilots
Number of RTPB pilots from various vendors and PBMs have been introduced and
are gaining traction
While promising, pilots have limitations including:
No current solution provides coverage information for all payers
Solutions use different syntaxes, hindering interoperability and
interconnectivity
RTPB Standard
NCPDP RTPB Task Group is developing an RTPB standard that will have two
standard formats (Telecom and SCRIPT) and one implementation guide for the
real-time exchange of data between providers and payers. RTPB transaction will:
Establish patient eligibility, product coverage, and benefit financials for a
chosen product and pharmacy
Identify coverage restrictions, alternative products, and benefit alternatives
when they exist
Status of RTPB Adoption
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Changes to Lower Drug Prices in Medicare Advantage and Part D
2018 proposed rule takes steps to increase transparency and
accelerate the use of RTPB solutions in Part D
Proposes that each Part D plan adopt a RTPB tool of its
choosing by January 1, 2020
Aggressive timeline may pose challenges for the industry
No RTPB standard currently in place
RTPB and CMS Proposed Part D Rule
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Background:
A private-sector initiative that is leveraging HL7 Fast Healthcare Interoperability
Resources (FHIR) to improve data sharing in value-based care arrangements
Solution is built around specific use cases
Goal:
Develop a resource that functionally serves as the RTPB for medical benefits
Coverage Requirement Discovery Use Case:
Providers need to easily discover which payer-covered services or devices have:
Requirement for PA or other approvals
Specific documentation requirements
Rules for determining need for specific treatments/services
With a FHIR-based API, providers can discover in real-time specific payer
requirements that may affect payer coverage of certain services or devices
HL7 Da Vinci Project
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Consensus:
Encourage the use of programs that selectively implement prior
authorization requirements based on stratification of health care
providers’ performance and adherence to evidence-based medicine
Encourage (1) the development of criteria to select and maintain
health care providers in these selective prior authorization
programs with the input of contracted health care providers and/or
provider organizations; and (2) making these criteria transparent
and easily accessible to contracted providers
Encourage appropriate adjustments to prior authorization
requirements when health care providers participate in risk-based
payment contracts
Selective Application of PA
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Potential technological solutions:
Payers can use data analytics to monitor provider performance to
see which providers have high PA approval rates to exempt them
from PA programs
“Gold-carding” programs
Payers will continue to use data analytics and monitoring
to make sure that gold-carded providers do not change
their prescribing/ordering habits
Challenge: Gold-carding program information must be integrated
within EHRs so payer-specific exemptions are relayed to the
provider at the point of care/prescribing
Selective Application of PA
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Consensus:
Encourage review of medical services and prescription drugs
requiring prior authorization on at least an annual basis, with
the input of contracted health care providers and/or provider
organizations
Encourage revision of prior authorization requirements,
including the list of services subject to prior authorization, based on
data analytics and up-to-date clinical criteria
Encourage the sharing of changes to the lists of medical
services and prescription drugs requiring prior authorization
via (1) provider-accessible websites; and (2) at least annual
communications to contracted health care providers
PA Program Review and Volume
Adjustment
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Potential technology solution:
Payers can use data analytics to identify what drugs and
services have high approval rates and remove these from
the PA list
Removing high-approval drugs and services from the PA
list eliminates unnecessary work for both payers and
providers, saving time and money
Challenge: Payers must continually update coverage data
so that current, accurate PA requirements are available in
EHRs at the point of care
PA Program Review and Volume
Adjustment
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Consensus:
Encourage sufficient protections for continuity of care during a
transition period for patients undergoing an active course of
treatment when there is a formulary or treatment coverage change
or change of health plan that may disrupt their current course of
treatment
Support continuity of care for medical services and
prescription medications for patients on appropriate, chronic,
stable therapy through minimizing repetitive prior authorization
requirements
Improve communication between health care providers, health
plans, and patients to facilitate continuity of care and minimize
disruptions in needed treatment
Continuity of Patient Care
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This area does not have fully developed solutions
Improvements in payer system communication and
interoperability could facilitate information exchange
between payers
Potential technological solution:
Blockchain/shared ledger technology
After a patient switches plans, technology could allow payer
to see what treatments a patient previously utilized and
could avoid unnecessary repetition of utilization
management processes
Potentially very useful for step therapy requirements
Challenge: Security measures for sharing protected health
information through blockchain technology have not been
developed
Continuity of Patient Care
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Leveraging Social Media for
PA Policy Reform
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New grassroots website: FixPriorAuth.org
Physician and patient tracks
Social media campaign drives
site traffic and conversation
Call to action: Share your story
Most impactful stories
collected in site gallery
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Impressions: +8.0 million
New users: +74,000
Engagements: +340,000
Patient/physician stories: +500
Petitions signed: +89,000
(since mid-October)
FixPriorAuth.org: Grassroots Results Since
July 2018 Launch
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Story
Story
Story
Story
Story
YOUR PRIOR
AUTHORIZATION
STORIES MATTER
FixPriorAuth.org
Story
Story
Story
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Please share our videos and resources!
ama-assn.org/prior-auth
fixpriorauth.org
AMA Resources
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Heather McComas, PharmD, Director, Administrative Simplification
Initiatives, AMA - heather.mccomas@ama-assn.org
Tyler Scheid, J.D., Senior Policy Analyst, Administrative
Simplification Initiatives, AMA tyler.scheid@ama-assn.org
Reminder: Please complete online session evaluation
Questions?